A return of the infectious diseases in rural America
Residing in Coffeyville KS, we all heard about the famous “dominoes gang” in Joplin MO, visiting the health clinics and soon, we discovered that a group of men in the 60’s and 70’s were holding late night activities in which they were playing games and having sex with one another. A large number of them showed up in clinics, infected with syphilis and other sexually transmitted diseases like chlamydia etc.
I remember then, we experienced a similar problem in the nursing homes around the city of Bridgeport CT during the mid-1990’s. We also discovered that younger prostitutes were visiting the nursing home to provide their services to the aging residents and sex was included as a gratuity. The alarming number of residents contacting sexually transmitted diseases became a problem for the community and for the institutions providing care. This was the time of the Colombian cartel and daily multiple gunshots were recorded and seen at the Level One trauma of Bridgeport Hospital soon to become Bridgeport Yale Health.
In Joplin, MO, many infected with venereal diseases started coming to the healthcare facilities. Older and younger men and women, teenagers and pregnant women presented in growing numbers and many cases of Syphilis were diagnosed and treated with Benzathine Penicillin G. Counties in the Midwest and in the West of the United States are becoming the most prone to have syphilis although cities like San Francisco, Las Vegas and Atlanta. are still showing high number of cases. The spreading of syphilis continues to be a problem in states like Missouri, Kansas, Oklahoma and Iowa creating a challenge for the healthcare organizations. Rural areas tend to have less access to healthcare and these clinics are less skilled in diagnosing such disease. Non marital sex and homosexuality encourage the spread of the sexually transmitted diseases among these populations.
Statistics from the Kaiser Health News in 2012 have demonstrated that Syphilis has more than quadrupled and last year cases for other sexually transmitted diseases have also jumped from 425 to 1896. More cases of syphilis were registered to at least an eightfold for the cities of Saint Louis and Kansas City. Cases of Syphilis skyrocketed from rural Missouri across the state. Centers which generally treat 5 cases are now seeing 32 cases around Kansas City and St Louis. In 1989, the CDC had plans to eradicate the sexually transmitted diseases nationwide.
Syphilis is indeed, treatable and curable but can cause permanent neurological problems, blindness, paralysis and even death. This disease is back also in part because of an increasing drug use. Unfortunately, the health officials may be losing the fight because of the federal and state cuts in health funding and the crumbing public health infrastructure. It is amazing that such a disease which once, was almost eradicated in the modern western, is bouncing back. The young are afraid to go to the clinics by fear of the disease being reported to their parents or that they may be the subject of gossiping. Many men are not telling the truth to their family by fear they may discover that they are performing sex with other men as well. Often, one may have no idea that their partner cheated in their relationship. More, the examining physician may have never seen lesions of secondary syphilis or may have never thought about asking the disease.
This current epidemic of syphilis and other sexually transmitted disease, appears to be more prevalent in men having sex with men and in 2013, an alarming number of women with the disease facilitated as well an alarming jump in congenital syphilis, causing miscarriage, birth deformities, stillbirth and other complications.
Syphilis is spreading to non-urban Missouri, Kansas cities and with it, an increase amount of cases of HIV/AIDS, Viral Hepatitis and Sexually transmitted diseases. In a parallel, the Center for Control Disease (CDC) reported a rising number of women who have contacted syphilis and the men who used to be their partners, self-reported the use of methamphetamines, heroin or other intravenous drugs. Public health officials report as well, an increase in drug use with the risk of trading sex for drugs. Dr. Hilary Reno is an Assistant-Professor at the Washington University School of Medicine, in St Louis MO who has been researching the relation between the Syphilis transmission and the use of drug in the states of Missouri and Kansas. She pointed out that more than half of the studied cases from 2015 to June 2018, were also associated to the use of drugs. We have to remember that in 2015, 4,5 million people were infected with Syphilis and 107,00 deaths were recorded in the United States. The rate of infection has increased with the turn of the new millennium in many countries, often associated with the human immunodeficiency virus (HIV). Promiscuity, Sex without condom, Prostitution, unsafe sexual practices and homosexuality have contributed to the propagation of the disease. In a side note, we have to remember that the first country in the world to have eliminated “mother to child transmission” of Syphilis, was Cuba.
Unfortunately, there is less federal funding for Sexually Transmitted Diseases (STD) Prevention although the number of cases have quadrupled in the Midwest. The resources stayed stagnant in Texas, New-York, Oregon. Many states have allocated supplemental money to fight this problem confronted by the local clinics in providing also transportation. We are facing more obstacles with the technology actually available. Sexual partners were more reachable with the various anonymous “Apps” and tracking back those partners becomes more difficult. Many educational programs on Instagram, Grindr, Facebook etc. have been tried to minimize the situation. Dr. H. Reno believes that perhaps, the state of Missouri should contribute fairly to eliminate the problem. Unfortunately, nationwide, health clinics function with limited hours of service have reduced the capability in screening with added cost to patients looking for services.
It is an important battle that we cannot afford to lose in the Tornadoes’ Alley and anywhere else in the United States of America. We only have to remember that Syphilis is a sexually transmitted disease caused by a bacterium: “The Treponema Pallidum”. We learned that four stages are recognized in a Primary, Secondary, a latent and a tertiary form. The primary stage is manifested a painless chancre, firm and non-itchy less than 2 centimeters in diameter unless there are more than one present. In the secondary stage, the presence of a rash involving the palms and the soles. Occasionally, there may be sores in or around the mouth or the vagina or the rectum. A latent form can last for years without showing any specific symptoms but finally, a tertiary phase will present with typical lesions called “Gummas” (soft and non-cancerous growth), neurological problems with “Tabes Dorsalis” and Paralysis or Heart problems. Our beloved professor Victor Boyer, in his unique style at the State University of Haiti, School of Medicine and Pharmacy, was so proud in his lectures to define this disease, as the “great imitator”. Because all the symptoms presented at different phases can be found in many other diseases
We have learned about the origins and we were told that many believe that this Syphilis was contracted by humans after the Spanish conquerors developed the habits of performing sex with sheep. Nowadays, the disease is most commonly contracted and spread through sexual activity. It can be transmitted congenitally from mother to the baby during delivery or at birth during its passage. Sex without condom, Prostitution, unsafe sexual practices and homosexuality have contributed to the propagation of the disease. In a side note, we have to remember that the first country in the world to have eliminated “mother to child transmission” of Syphilis, was Cuba, our neighbor. In Haiti and other Caribbean countries, the bacteria can trigger other non-venereal forms of the disease like “Yaws” (Pertenue) or “Pinta” (Carateum). or a non-venereal form of Syphilis (Endemicum) which are not typically transmitted sexually. The search for the bacteria dead or alive, through serous fluid from a chancre or any lesion, using a dark field Fluorescein microscopy, can be helpful: The Direct Fluorescent Antibody (DFA) detects the antibodies attached on the proteins while the Polymerase Chain Reaction (PCR) detect the genes.
All pregnant women in the United States are mandatorily tested. Blood tests are divided into treponemal and non-treponemal tests. The Venereal Disease Research Laboratory (VDRL) is a non-treponemal test as well as the Rapid Plasma Reagin (RPR). Occasionally, a false positivity can be seen with some viral infections like Varicella (Chickenpox) or Measles, lymphoma, Tuberculosis, Malaria, Connective tissue diseases etc. On the other side, a treponemal test such as Treponemal Pallidum Particle Agglutination (TPHA) or Fluorescent Treponemal Antibody Test (FTA-Abs) look for particles or antibodies to the Treponema. Further, during the stage of Neurosyphilis, large numbers of lymphocytes with a high protein level may be found in the cerebrospinal fluid and can be used as a diagnostic test.
We would not miss the opportunity to remind one that the risk of sexual transmission of Syphilis can be reduced by the use of a latex or a polyurethane condom. More as we already mentioned it above, Syphilis can be treated with Benzathine Penicillin with an intra-muscular injection. Often, one will present with a Penicillin allergy and the drug of choice will be Tetracycline or Doxycycline. In cases with advanced disease and Neurosyphilis, IV injections are recommended and even intra thecal mode of injections have been performed. One may expect fever, headache and muscle spasms, aa a reaction often encountered during the treatment and known as “Jarisch-Herxheimer “ reaction.
Maxime Coles MD
References:
1- Kaiser Health News (KHN) Editorial from Kaiser Permanente 4-24-19
2- Upswing of Syphilis in Women with HIV
3- USPSTF: “Screen All Pregnant Women for Syphilis Early.” Medscape Today.
4- Syphilis: CDC Fact Sheet: November 2015/June 2915
5- GBD 2015 Disease and Injury Incidence and Prevalence: “Global, Regional and National incidence and prevalence and years of disability for 310 diseases and injuries. 1990-2005. Lancet 388 (10053) pp. 1545-1602.
6- GBD 2015 Mortality and Causes of Death: “Global Regional and National Life Expectancy, all causes Mortality and all cause specific mortality for 249 causes of death 1980-2005. Lancet 388 (1053) pp. 1459-1544.
7- “Pinta” Nord 13 April 2018.
8- Woods CR: “Congenital syphilis persisting pestilence”. Pediatr Infect Disc J 28 (6) pp 536-537.
9- Armelagos, George J: The Science behind Pre-Columbian Evidence of Syphilis in Europe: Research Documentary”. Evol. Anthropol (21): pp 50-57.
10- Rothschild, BM: “History of Syphilis” Clinical Infectious Diseases 40 (10) pp 1454-1463.
11- Winters, Adam: “Syphilis: New York: Rosen Pub Group p. 17.
12- Dayan, L Ooi C:” Syphilis Treatment old and new”. Expert Opinion on Pharmacology. 6 (13): pp 2271-2280.
13- Reid, Sasil A: “Myths and realities of Caribbean history”. Tuscaloosa University of Alabama Press. p 113.
14- “Transmission of Primary and Secondary Syphilis by oral Sex”: Morbidity and Mortality Weekly Report; (Chicago Illinois 1988-2002.